Quiz 34, 10th of May 2019

Question 1

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A 30 year old pregnant lady is referred to you by her General Practitioner because of suspected pulmonary embolism (she has had mild dyspnoea for 2 days). We have been scanning a lot of pregnant patients because d-dimers are often (falsely) positive and so far no single rule out strategy turned out to be reliable enough. Until now maybe. Last week this paper was published in the New England about the YEARS algorithm for ruling out pulmonary embolism in pregnant patient. What did the authors find?

A: Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy

B: Of a total of 498 included patients, CT pulmonary angiography was avoided in 195 patients

C: During follow-up of the patients not receiving imaging, no patient had pulmonary embolism

D: All of the above

The correct answer is D

This algorithm uses the YEARS criteria to elevate the d-dimer cutoff to 1000 ng/ml if negative. This seems to be a viable clinical decision tool to rule out PE in pregnant patients and safely reduce CT use. Take note PE was only diagnosed in 4% of the study population (20 patients).


Question 2

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Which of the following statements is true about push dose vasopressors?

A: Phenylephrine may cause reflex bradycardia

B: Ephedrine has a short duration of action (< 15 minutes)

C: There is plenty of evidence to support the use of push dose noradrenaline in the Emergency Department

D: Adrenaline has a longer duration of action compared to Phenylephrine

The correct answer is A

emDOCS published about push dose vasopressors this week.

Phenylephrine is a pure alpha agonist that causes arterial vasoconstriction and an in increase systemic vascular resistance. It has no chronotropic effect and may lead to baroreceptor-mediated, reflex bradycardia. Ephedrine is an indirect alpha and beta-1 receptor agonist, it has extended duration of action (60 minutes). Evidence to support norepinephrine as a push dose pressor in the ED is lacking. Push-dose phenylephrine has a slightly longer duration of action compared to epinephrine (10 to 20 minutes vs. 5 to 10 minutes).

Push-Dose Vasopressors: An Update for 2019

Question 3

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Which of the following statements about Acetaminophen is true?

A: Dialysis is never indicated in Acetaminophen overdose

B: Patients with Acetaminophen overdose can present with altered mental status and a high anion gap metabolic lactic acidosis

C: Acetaminophen can cause a decreased INR in patients on Warfarin

The correct answer is B

Emergency Medicine Cases’ EM Quick Hits is about Acetaminophen (and more) this week.

Patients with a massive acetaminophen overdose (for example, > 500 mg/kg) may benefit from hemodialysis. These patients can present with altered mental status and a high anion gap metabolic lactic acidosis. Even normal dose acetaminophen can cause a rise of INR in patients on Warfarin.

EM Quick Hits 4 Acetaminophen Overdose & Warfarin Interaction, Dental Infections, MTP RABT Score, Statins for STEMI, Cricothyrotomy Tips

Question 4

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Which of the following statements is true about Ludwig’s Angina?

A: Ludwig’s angina is more common in females than in males at a 2:1 ratio

B: The diagnosis of Ludwig’s angina is typically made clinically and CT or MRI imaging is not beneficial

C: Oral intubation is not more difficult than usual in patients with Ludwig’s Angina

D: The biggest predictor for complications (like necrotizing fasciitis, carotid artery rupture, pericarditis, jugular vein thrombosis) is anterior visceral space involvement

The correct answer is D

Taming the SRU is all about Ludwig’s Angina this week. Although pretty uncommon in the ED, you HAVE to recognise this entity.

Ludwig’s angina presents in males more often than females at a 2:1 ratio. The diagnosis of Ludwig’s angina is typically made clinically, however obtaining CT or MRI scans of the neck can help determine the location and extent of the infection. Oral intubation is often difficult due to displacement of the tongue and swelling of the posterior pharynx. Anterior visceral space involvement is the biggest predictor for complications.


Question 5

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A 25 year old patient with sickle cell disease (SCD) presents with severe pain. He reports a pain score of 8, but is texting while waiting for the laboratory results. Which of the following is true about pain management in vaso-occlusive pain crisis?

A: Opioid addiction is more common in patients with SCD compared to opioid addiction in the general population

B: Always administer oxygen in patient with vaso-occlusive crisis

C: Patients with SCD often express their pain in an unusual way, leading to suspicion of drug seeking behaviour

D: Always give iv fluids in patient with vaso-occlusive crisis

The correct answer is C

The latest podcast on FOAMcast is about sickle cell disease.

Patients with Sickle Cell Disease often visit the emergency Department with pain crises or complications of the disease like infections. Patients live with pain at baseline every day and have acute pain episode as well. Therefore these patients may express their pain in an abnormal way. These patients may be in severe pain and look comfortable at the same time. Do not assume this is drug seeking behavior. You can prescribe NSAIDs, but 40 percent of patients have renal insufficiency due to renal infarction. Ketamine or a nerve block are a good options when the pain is refractory to opioids. Patients often need high doses of opioids, for many have some degree of opioid tolerance.

Routinely administering oxygen and iv fluids in vaso-occlusive crisis is no longer recommended. Acute Chest Syndrome is a whole different story though.

Emergent Issues in Sickle Cell Disease

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen